Wake Forest University Health Sciences

NIH Research Projects · FY 2026 · 2024-02

PROJECT SUMMARY Bariatric surgery is increasingly used to treat severe obesity and related comorbidities. However, clinical practice guidelines now recognize associated skeletal consequences, as mounting evidence implicates surgical weight loss in the onset of skeletal fragility. To address this, the randomized controlled trial, Strategies to Reduce the Onset of Sleeve Gastrectomy Associated Bone Loss (STRONG BONES; U01AR080969) is testing if the bisphosphonate, risedronate (a first-line osteoporosis drug), can effectively counter bone loss secondary to the most common bariatric surgical procedure, sleeve gastrectomy (SG). This trial is randomizing 120 SG patients (ages≥40) to 6 months of risedronate or placebo treatment, and assessing skeletal changes via dual energy x- ray absorptiometry (DXA), computed tomography (CT), and blood-based biomarkers at baseline, 6, and 12 months; yet, these modalities are not sufficient to measure bone microstructure changes that are expected with surgical weight loss and bisphosphonate treatment. The proposed ancillary study leverages the patient cohort, infrastructure, and data of the parent STRONG BONES trial, and enhances its scientific value by adding high- resolution peripheral quantitative computed tomography (HRpQCT) imaging to assess interventional effects on bone microarchitecture, density, and strength of the tibia and radius. HRpQCT is the only in vivo image modality with sufficient resolution (61µm) to assess trabecular and cortical microarchitecture. Using longitudinal HRpQCT imaging and micro-finite element (microFE) analysis of bone strength, we can pinpoint local areas of dynamic bone formation or resorption and examine the mechanoregulation of this bone remodeling. The ancillary study will add HRpQCT measures of the STRONG BONES participants, with four HRpQCT scans (distal tibia and radius; diaphyseal tibia and radius) per visit (baseline, 6 and 12 months). Building on the parent trial, this ancillary study is a timely, efficient, and cost-effective means to definitively test the scientific premise that risedronate can attenuate deterioration of bone microarchitecture, density, and strength secondary to SG. Specific Aims are to: (1) Determine the effect of risedronate vs. placebo on 12-month change in microFE-derived bone strength (failure load) of the tibia and radius following SG. (2) Determine the effect of risedronate following SG on 12-month change in HRpQCT-acquired trabecular and cortical bone mineral density and microarchitecture (e.g., trabecular number, spacing; cortex thickness, porosity). (3) Investigate the localized remodeling and mechanoregulation of bone in the microenvironment, and the associations of HRpQCT metrics with other skeletal outcomes obtained in the parent study [DXA, CT, and bone turnover/tissue-crosstalk biomarkers] to elucidate biological mechanisms underlying SG-associated bone loss and potential counteractant effects of risedronate. Definitive data supporting use of an existing, cost-effective, and safe medication to offset rapid degradation of bone microstructure after SG has the potential to shift current clinical practice paradigms, and offer mechanistic insight on the biology of SG-associated bone loss and risedronate as a treatment option to counteract microstructural tissue damage.

NIH Research Projects · FY 2026 · 2024-02

ABSTRACT Relative to matched normal tissue, recent large scale sequencing efforts indicate that colorectal cancer (CRC) tumors are specifically enriched in loss of function mutations in mitochondrial DNA (mtDNA); however, the significance and functional consequences of high mtDNA mutational burden in CRC remains unknown. Given that mtDNA encodes critical subunits in 4 out of the 5 complexes of the electron transport chain (ETC), high mtDNA mutational burden suggests that CRC incidence and/or pathogenesis is dependent on disruptions in mitochondrial respiration. On the contrary, impairing tumor mitochondrial respiration, via pharmacological ETC inhibitors or deletion of genes required for the function of the respiratory complexes, blunts tumor growth across many tumor types, including CRC. Together, these seemingly contradictory data sets highlight an intriguing paradox: how do accumulated mtDNA mutations support CRC tumorigenesis, if mitochondrial oxidative metabolism is inherently required for tumors to grow? Generating targeted and efficient CRC therapeutics is dependent on answering this question. In preliminary studies using purified human CRC mitochondria we confirmed that, relative to matched normal, CRC tumors have more mtDNA mutations and discovered that functional bioenergetic deficiencies exclusively localize to mitochondrial complex I, with 100% (12/12) of clinical CRC tumors displaying partial loss-of-function in complex I activity. To model human CRC bioenergetic deficiencies in the mouse, we reduced complex I activity by 50% in the colon using tissue-specific deletion of the complex I accessory subunit NDUFS4. Partial complex I inhibition increased both tumor number and size following CRC initiation with AOM/DSS and induced a pronounced growth advantage in tumor-derived organoids. These results demonstrate that partial complex I loss of function provides a growth advantage sufficient to accelerate CRC outgrowth. Surprisingly, despite it's role as the initiating complex of the ETC, complex I deficient CRC tumors respired normally; although at the expense of increased matrix NADH/NAD+. Additional bioenergetic analysis revealed that CRC tumors circumvent NADH/NAD+ hyper-reduction to sustain mitochondrial oxidative metabolism by uncoupling respiration from ATP synthesis. Thus, our preliminary data indicate that CRC mitochondria exhibit unique metabolic rewiring that allows respiration to proceed despite partial complex I inhibition. The goal of this project is to test the hypothesis that partial complex I deficiency induces increased NADH/NAD+ and/or respiratory uncoupling that accelerates CRC growth. Successful completion of this project will establish the mechanisms by which complex I deficiency accelerates CRC. Given that complex I genes are the most frequently mutated mtDNA genes across tumor types, these findings will provide broader insight on the interplay between mitochondrial function and cancer.

NIH Research Projects · FY 2026 · 2024-02

Project Summary The discovery of brain cells-derived small extracellular vesicles (sEV), broadly known as exosomes, has led to studies examining their role as `liquid biopsies' for Alzheimer's disease and related dementias (ADRD). sEV offer a unique, repeatable, and less invasive tool to discover molecular changes in multiple cell types of the brain during Alzheimer's disease (AD) pathogenesis. Here, we propose to test the usefulness of brain cells-derived sEV to discover the molecular pathways targeted by a dietary intervention against AD and to identify individuals responsive to such intervention. Earlier studies have shown the beneficial effects of ketogenic diet (KD) against ADRD, and we have developed a KD version known as a `Modified Mediterranean-Ketogenic Diet (MMKD)' with improved nutrition and compliance, and recently in a pilot study published its promising beneficial effects in individuals with amnestic mild cognitive impairment (aMCI). Based upon these exciting results, a phase II study (BEAT-AD: Brain Energy for Amyloid Transformation in AD, R01AG055122, PI: Craft) was initiated to test MMKD efficacy in adults with aMCI in comparison to a low-fat American Heart Association Diet (AHAD). In BEAT-AD, all participants (100 adults with aMCI) undergo comprehensive cognitive testing, brain MRIs, apoE genotyping, and metabolic profiling. Additional assessments include CSF analysis of AD biomarkers and PET imaging of the brain for amyloid and tau deposition, ketone uptake, and glucose metabolism. Together, these `gold-standard' measures will assess the efficacy of MMKD against AD but are unlikely to establish the effect of MMKD on key molecular determinants of aMCI brain. Additionally, there is no known blood-based biomarker to identify those individuals who would be most responsive to MMKD. To demonstrate the usefulness of sEV in understanding the molecular action of MMKD at the neuronal level, we obtained plasma samples from the completed pilot study and generated solid feasibility data, published recently in the journal Brain Communications. Based upon these exciting findings, we propose to further establish the effect of MMKD on glutamate-glutamate receptor-Aβ signaling, oxidative stress, and neuroinflammation in the BEAT-AD study. In this ancillary study, we will isolate various brain cells-derived sEV from the plasma of all 100 participants (both pre- and post-MMKD and –AHAD) and characterize in the following aims: Aim I: sEV characterization to assess the effect of MMKD intervention on glutamate signaling and synaptic plasticity-related biomarkers in individuals with aMCI; Aim II: sEV characterization to determine the effect of MMKD intervention on oxidative stress and neuroinflammation in individuals with aMCI; and Aim III: To characterize brain cells-derived sEV to predict response to MMKD intervention in individuals with aMCI. Outcomes will establish brain cells-derived sEV as liquid biopsies to non- invasively assess the effect of MMKD on molecular circuitries in the aMCI brain and their clinical application in screening individuals responsive to MMKD, leading to an evidence-based `personalized approach' to AD.

NIH Research Projects · FY 2025 · 2024-02

PROJECT SUMMARY Hepatitis B virus (HBV) infection remains an incurable disease. Despite the availability of vaccines and potent anti-viral drugs, nearly 300 million people worldwide are infected with HBV. The challenge with curing HBV is the persistence of the virus’ genome in the form of a double-stranded covalently closed circular DNA, or cccDNA, in the liver cells of patients. Unfortunately, the most modern nucleoside analogs (NUC) drugs do not eliminate cccDNA and infection is never fully cleared. To ultimately achieve a cure for HBV, a new class of drugs are needed that can specifically induce degradation or loss of the cccDNA. This project will address the need for cccDNA targeting drugs by proposing to develop peptide nucleic acids, or PNAs, as a therapeutic. PNAs are similar to small nucleic acid therapeutics that have already been FDA approved, like Patisiran or Nusinersen. However, unlike other small nucleic acid drugs, PNAs have the unique ability to directly bind to double-stranded DNA (dsDNA) and induce damage or degradation. And unlike some biologics are being developed that can also bind and degrade dsDNA, like CRISPR-Cas systems or TALENs, PNAs are extremely stable, exhibit low toxicity, are highly sequence specific, and are deliverable without formulation of as nanoparticle formulations. PNAs can also build on the successful development of FDA-aproved liver-targeted nucleic acid therapeutics like Patisiran. This project will first establish sensitive cccDNA detection and characterization methods to track changes in cccDNA during the course of experimental treatments with PNAs. It will design, synthesize and test a small library of PNAs that can target and potentially induce the degradation of cccDNA. These will include two PNA binding modes to the cccDNA and DNA-modifying chemical conjugates, including DNA alkylation and phosphodiester bond cleavage. These PNAs will be characterized in vitro and in cell culture models of HBV. The best PNA designs will then be tested in mouse models using two modes of delivery, direct injection or lipid nanoparticle (LNP) formulation, and their acute toxicity, immunogenicity, and tissue distribution characterized. Finally, the best PNAs will further characterized for their dosing, duration of effect, and ability to eliminate cccDNA in two mouse models of HBV. Together, these results will evaluate the potential of PNAs to serve as a drug candidate for clearing cccDNA from infected animal models of HBV. If successful, one or more lead PNAs could be identified for immediate preclinical development to cure HBV, either alone or combined with currently prescribed NUCs or other antivirals.

NIH Research Projects · FY 2026 · 2024-02

PROJECT ABSTRACT Tobacco use has alarmingly high rates among people with HIV (PWH), 43% compared with 15% in the general population. Due to the development of highly effective treatments for HIV and the resulting increased longevity among PWH, this population now loses more life years to smoking than to HIV infection itself. Novel and effective models to deliver wider reaching smoking cessation interventions for PWH are highly needed and indicated as a priority for NIH. Digital therapeutics (DTx) may be a novel, scalable, and highly available approach for engaging and treating smoking in this population. However, although DTx for smoking cessation have been shown effective in the general population, no large trial to date has examined the effectiveness of a tailored DTx for smoking cessation in PWH, and no implementation science work has examined barriers and facilitators of implementation of DTx for smoking cessation in this population. In prior early-phase work, we developed LTQ-H, a user-centered smoking cessation DTx tailored to the needs of PWH (R21 CA243911). This novel DTx is based on a mental health intervention -- Acceptance and Commitment Therapy -- that has been shown effective as a treatment for smoking cessation. LTQ-H also provides recommendations from U.S. Clinical Practice Guidelines. We tested LTQ-H in a remote pilot randomized controlled trial. Consistent with our conceptual model, results indicated significant effects on the pilot’s primary outcomes: (1) high levels of objective user engagement, (2) adherence to smoking cessation content, and (3) features that effectively addressed our targeted components (e.g., mental health, cognitive deficits, and HIV stigma). LTQ-H’s quit rates were high compared to prior mobile behavioral smoking cessation interventions for this population, though the trial was not powered to detect smoking outcome differences with the control group. The trial recruited a demographically diverse sample of patients from 9 U.S. states and established relationships with several HIV clinics in the eastern U.S. In this project, we will conduct a type 1 hybrid effectiveness implementation trial informed by the Consolidated Framework for Implementation Research. The trial aims to: (1) compare the effectiveness of LTQ-H to QuitGuide, an evidence-based DTx for the general population, and (2) evaluate acceptability, appropriateness, costs, and feasibility of DTx for smoking cessation among PWH and HIV clinics. The trial focuses on two high-priority research areas in the NIH Strategic Plan for HIV-Related Research and the Cancer Moonshot Research Initiative: (1) the incorporation of state-of-the-art technology to improve access to hard-to-reach populations and settings, and (2) the use of implementation science to address cancer health disparities. This study will generate the necessary clinical effectiveness data and implementation strategies for the general application of DTx in a future type 3 hybrid trial.

NIH Research Projects · FY 2025 · 2024-02

PROJECT SUMMARY Age-related macular degeneration (AMD) is the most common cause of irreversible visual impairment in the US, and restoring retinal function in AMD patients remains a big challenge. Retinal pigment epithelium (RPE) degeneration is the hallmark of advanced “dry” or non-neovascular AMD with no treatment available. The implanted retinal pigment epithelial cells (RPEs) or a patch of RPE, generated from induced pluripotent stem cells (iPSCs), provide great potential in the treatment of AMD. Autologous iPSCs possess therapeutic potential with less immunogenicity and have less ethical controversy than human embryonic stem cells-based therapies. Two phases are required from somatic cells to generate mature RPEs: iPSCs are reprogrammed from different somatic cell sources located at peripheral blood, skin, or other epithelial tissues, and then iPSCs are guided to differentiate to functional RPEs (RPEsiPSC). Despite current progress in generating RPEs from somatic cells, several barriers remain in their clinical application, and there is an urgent need to develop an optimized strategy with higher efficiency and rapid differentiation kinetics in the generation of RPEsiPSC. Human primary USCs, as renal progenitors first discovered by the PI’s team, are easily accessible and possess robust cell proliferation and renewal capacity for tissue regeneration. Our previous studies demonstrated that iPSCs reprogrammed from USC (u-iPSCs) more efficiently and rapidly than iPSC from other cell sources. u-iPSC efficiently differentiated into neurocytes, but RPEsu-iPSC have not been developed yet. The long-term goal of this proposal is to use RPEs generated from autologous USC-derived iPSCs (RPEsu-iPSC) to reestablish the interaction with photo‑receptors and prevent degeneration of the retina, restoring the vision function for patients with AMD. The overall objective of this R21 study is to generate pure RPEs from u-iPSC (RPEsu-iPSC). Our central hypothesis is that u-iPSC reprogrammed from USC (epithelial progentior cells) are more efficiently and rapidly differentiated into mature RPEs (epithelalial lineage cell) with specific makers and durable tight junction, compared to iPSC from mesenchymal cell lineages (i.e, skin fibroblasts and blood mononuclear cells). Thus, the specific aim of this study is to develop and optimize a strategy for generating reliably archived human RPEsu-iPSC. We will determine the efficiency of RPE differentiation from u-iPSCs and assess the function of RPEsu-iPSC compared to that of iPSC from skin and blood cells, with adult human primary RPE as a control. We expect that USC obtained non-invasively from AMD patients could be an optimal cell source for generating mature RPEsu-iPSC in a cost-effective manner for personalized medicine in the treatment of AMD. This in vitro differentiated human RPEsu-iPSC will be highly valuable and pave the ground for a future R01 proposal on an in vivo study with autologous RPEsu-iPSC. The broader impact is that RPEsu-iPSC might be used for RPE research, in vitro ocular disease modeling, and toxicity testing. An in vitro model of RPEsu-iPSC might provide a superior platform for personalized drug discovery compared to existing human RPE cell lines or animal cell sources.

NIH Research Projects · FY 2026 · 2024-01

Cardiovascular disease is the leading cause of death world-wide. Two main reasons for this are atherosclerosis, which narrows major arteries, and thrombosis, which results in occlusive blood clots. Despite the ongoing health burden, the translation of experimental therapies has stalled. A common challenge for therapies addressing atherosclerosis and thrombosis is their poor localization in sites of disease such as atherosclerotic plaque and thrombi. Thus, there is a pressing clinical need to develop novel targeting strategies to improve therapeutic accumulation in these sites. I hypothesize that cell-mediated delivery of nanoparticle-encapsulated therapies will improve site-specific therapeutic accumulation to treat atherosclerosis and thrombosis. To test this, I will employ next-generation nanoparticle synthesis technologies (Flash NanoPrecipitation (FNP) and inverse FNP) coupled with cell-mediated delivery for the directed delivery of therapies to atherosclerotic plaque and thrombi. FNP and iFNP are new polymeric nanoparticle synthesis technologies that uniquely address challenges related to scalability for manufacturing. To direct these nanoparticles to sites of vascular injury, I will employ cell-mediated delivery. In this method, nanoparticles can be either loaded into cells ex vivo or decorated with ligands to exploit interactions with internalization receptors specifically expressed on pertinent cells in vivo. Atherosclerosis and venous thrombosis are two disease settings characterized by immunological cell infiltration; as such, they are uniquely suited for the application of cell-mediated delivery of nano-encapsulated therapies. With respect to atherosclerosis, circulating activated monocytes infiltrate into the inflamed arterial wall and differentiate into macrophages, which are centrally important to atherogenesis. Notably, these cells over-express an internalization receptor for folic acid: folate receptor-beta. Herein, I will develop therapeutic-carrying nanoparticles conjugated to folic acid, with the goal of being specifically internalized by activated monocytes/macrophages thereby employing these immune cells as delivery vehicles for the localization of drug to atherosclerotic plaque. As oxidative stress is a key driver of atherosclerotic progression, I will focus on delivering antioxidant interventions. An equally innovative strategy using exogenous neutrophils can be used to treat thrombosis. A key challenge in our treatment of thrombosis is a time-dependent decrease in treatment efficacy, as aging thrombi become increasingly difficult for clot-dissolving (thrombolytic) enzymes to penetrate. Moreover, high doses of thrombolytic enzymes can lead to dangerous bleeding. I propose to address this penetration issue by utilizing neutrophils as cell carriers of thrombolytic proteins encapsulated in polymeric nanoparticles. Neutrophils actively infiltrate thrombi, and can be rapidly loaded ex vivo with polymeric nanoparticles. Employing neutrophils as a delivery vehicle would address the issue of clot penetration and could circumvent the problem of bleeding. Overall, my project aims to develop novel cell-mediated therapeutic delivery platforms with the goal of preventing atherosclerotic plaque progression and treatment of thrombosis.

NIH Research Projects · FY 2026 · 2024-01

PROJECT SUMMARY Clinical decision support (CDS) systems were developed to improve the quality and safety of medical practice. At present, however, these systems are generally not tied to clinical outcomes, decreasing their effectiveness. Additionally, CDS is often built one institution at a time, so effective CDS does not scale and achieve its potential. Our proposed study aims to expand existing CDS metrics and data sharing infrastructure across six CTSA hubs. In doing so, this study seeks to fully realize the effectiveness of CDS systems through the leveraging of electronic health record (EHR) data and ultimately reducing the barriers to highly efficient data interoperability. Our hypothesis is that the development of translational metrics and data sharing infrastructure across multiple institutions will address both translational science and research barriers, increasing the efficiency and effectiveness of CDS, and improving clinical outcomes. Through this study, we will create a centralized and highly efficient data-sharing infrastructure to support translational clinical decision support analysis and benchmarking of performance across sites. We will ground our work in the EPIS Framework, which consists of Exploratory, Preparation, Implementation, and Sustainment phases. The EPIS conceptual framework is well-known, reliable, efficient, and scientifically valid for our approach. We will ground the work from all five aims (across both the UG3 and UH3 phases) in this framework, testing our approach for gains in efficiency, collaborative performance, and translational outcomes. In the UG3 Phase (Aims 1-3) we will create the processes and governance for the Translational CDS Collaborative, build the analytical infrastructure and test its performance, and establish feasibility of the collaborative beyond the initial study sites. After reaching our milestone goals, we will progress into the UH3 Phase (Aims 4-5), which will evaluate the impact of the collaborative on clinical outcomes and expand the capabilities and impact of the infrastructure. The proposed work will set the foundation for efficiently and effectively creating, disseminating, implementing, and evaluating electronic CDS. We will create a centralized collaborative learning platform and shareable resources for CTSI sites, acting as an innovation nidus for the entire informatics and clinical research community, enabling data-driven CDS design recommendations and frameworks. This CTSA-sponsored project will aggregate the expertise, talent, and resources we have at our individual sites into a collective program that is designed to reframe CDS as a translational catalyst and enabler. The multi-site foundation we propose will serve as the starting point for the development of next-generation analysis of CDS data, the effective design of impactful CDS-based interventions, and innovative approaches to solving some of the largest challenges in modern informatics and clinical practice.

NIH Research Projects · FY 2026 · 2023-09

Project Summary Damage to visual cortex by stroke or trauma often results in contralateral blindness, or hemianopia, a condition that markedly compromises quality of life. The goal of this project is to develop a primate model of multisensory rehabilitation from hemianopia. Although several therapeutic strategies have been tried over the years, they have met with limited success, mostly restricted to the recovery of visuomotor orienting without visual awareness. Recently, a novel, simple, noninvasive sensory training paradigm has been developed that produces far more promising and rapid results. This paradigm involves repeatedly presenting spatiotemporally congruent visual and auditory cues to the blinded hemifield, which engages plasticity within circuits that process both visual and auditory signals. Results from hemianopic cats have shown that, after several weeks of such multisensory exposure, animals recover the ability to detect and localize visual stimuli and perform rudimentary visual pattern discrimination in the contralesional field. Similar findings were recently obtained in two human patients, who were given a very similar multisensory rehabilitation paradigm, and were able to verbally report on their awareness of visual stimuli in the previously blind hemifield. However, the extent of visual capabilities that can be recovered is unknown. To overcome the limitations of using the cat model to explore these limits and its neurobiological bases, we propose to establish a primate model of multisensory rehabilitation with which we can detail the effectiveness, operation, and neural correlates of the paradigm. Our immediate objective is to examine the most pressing questions relating to the psychophysical and neurophysiological outcomes of the multisensory rehabilitation of hemianopia, including the quantification of visual stimulus detection and visual feature discrimination capacities. To do so we will assess the behavioral and perceptual capabilities of trained hemianopic monkeys on a battery of visual psychophysical tasks before and after multisensory rehabilitation and assess changes in the neurophysiological properties of subcortical and cortical areas (superior colliculus and area LIP) believed to underlie this recovery. These results will provide a foundation for understanding the mechanisms underlying this novel rehabilitative approach so that optimal translational strategies can be developed to ameliorate this condition in human patients.

NIH Research Projects · FY 2026 · 2023-09

PROJECT SUMMARY/ABSTRACT Although anti-VEGF therapies have shown impressive benefits for patients with wet form age-related macular degeneration (AMD), there is no effective treatment for dry AMD, a major unmet clinical need. Retinal pigment epithelium (RPE) and retina dysfunction and degeneration are the major pathological features in dry AMD. Deficient mitochondrial function and disturbed lipid metabolism in the RPE are believed to play key pathogenic roles in these pathologies of dry AMD. However, the molecular mechanism for the dysregulation of lipid metabolism in the RPE with AMD is elusive. Peroxisome Proliferator-Activated Receptor α (PPARα) is a transcription factor. It regulates lipid metabolism, and thus, PPARα agonists are used clinically to treat dyslipidemia. Although our recent study showed that PPARα has a protective role in the retina, the association of PPARα with the pathogenesis of AMD remains unknown. Our preliminary studies demonstrated that PPARα levels are down-regulated in the retina and RPE of human donors with dry AMD and in two animal models with partial AMD phenotypes. Furthermore, activation or expression of PPARα in the RPE partially protected the retina and RPE against oxidative stress-induced RPE and retina damage. We have demonstrated that PPARα knockout (KO) alone resulted in age-related ERG decline, retinal degeneration, abnormal RPE cell morphology, enlarged RPE cell size, impaired RPE barrier, and increased microglia/macrophage adherence to the RPE. PPARα KO also induced lipid accumulation in the RPE and Bruch’s membrane. Thus, we hypothesize that PPARα is a major regulator of fatty acid oxidation (FAO) and lipid homeostasis in the RPE, and essential for maintaining normal structure and function of the RPE and retina. In this project, we will use our newly generated RPE-specific PPARα conditional KO (PPARα-CKO) mice and transgenic (PPARα-Tg) mice expressing PPARα in the RPE for the proposed studies. We will analyze changes in RPE barrier function, RPE cell morphology and cell size, ERG, retinal and photoreceptor cell layer thicknesses, subretinal inflammation, and lipid accumulation in the RPE and Bruch’s membrane of PPARα-CKO mice under a regular diet or high-fat, cholesterol-rich (HFC) diet, to reveal if PPARα ablation in the RPE alone will induce retina and RPE pathologies, which will be accelerated and exacerbated by the HFC diet. We will also determine if PPARα ablation will decrease FAO and increase glycolysis in the RPE. Proteomic analysis of PPARα-CKO RPE will be performed to identify enzymes and lipid-binding proteins with changed levels in the RPE of PPARα-CKO mice. Further, we will investigate if PPARα-Tg mice will show alleviated, while PPARα-CKO mice will show more severe, RPE and retinal injury by oxidative stress. We will also explore the therapeutic potential of PPARα agonist fenofibrate against RPE and retinal dysfunction and degeneration in two genetic mouse models with some AMD phenotypes. The proposed studies will identify a new regulation mechanism for lipid metabolism in the RPE and has the potential to lead to the repurposing of an oral lipid-lowering drug for the treatment of dry AMD.

NIH Research Projects · FY 2025 · 2023-09

Lung cancer screening using low-dose computed tomography significantly reduces lung cancer mortality, the leading cause of cancer mortality in the United States. Despite its life-saving potential, lung cancer screening uptake remains extremely low among eligible populations. Multilevel barriers to lung cancer screening exist at the patient, provider, and health system levels. However, prior research assessing these barriers is limited by inadequate involvement of many communities affected by lung cancer (e.g., populations with lower access to health care) and by the exclusion of key health care staff (e.g., nurses) who often champion screening programs. Many health care interventions also lack trustworthiness, partly because they are often designed without community input. Little is known about how screening barriers can be addressed through implementation strategies that have an explicit goal to earn patient trust and improve lung cancer outcomes for all populations. Through three specific aims, this study will address these knowledge gaps. These aims are to: 1) identify multilevel barriers and facilitators to the implementation of lung cancer screening, 2) engage with community advisors and key stakeholders to identify multilevel implementation strategies to promote lung cancer screening, and 3) pilot test the feasibility of multilevel implementation strategies designed to improve lung cancer screening uptake (one at the patient level and one at the provider/system level). Overall, this innovative study will be among the first to respond to the need to increase lung cancer screening receipt for all populations. It will also lay the groundwork for a R01 application to evaluate the intervention pilot tested in this study.

NIH Research Projects · FY 2025 · 2023-09

SUMMARY Cancer patients suffer from a multitude of debilitating symptoms associated with cancer and cancer treatment, many of which are not relieved with prescription medications. In hopes of managing these symptoms, many patients are turning to cannabis, with recent estimates of cannabis use among cancer patients ranging from 24-40%, primarily for physical and neuropsychiatric symptom relief, despite limited evidence of benefits and uncertain risks. This is, in part, due to increased availability of cannabis as more states legalize use. The expanding cannabis market, with varying regulations, limited product standards and few marketing restrictions, has resulted in a marketplace filled with diverse product types (e.g., smoked cannabis, vapes, edibles, topicals) with unpredictable cannabinoid concentrations, often exceeding that of therapeutic benefit (THC>15%). These products are associated with acute intoxicating effects and long-term adverse effects. Furthermore, THC and CBD, the primary cannabinoids, may be hepatotoxic, affect the metabolism of chemotherapy, and result in drug interactions that could enhance chemotoxicity. Furthermore, cannabis’ immunosuppressive effects could dampen immune responses and alter the efficacy of immune checkpoint inhibitors. Despite this, patients generally report that cannabis improves cancer-related symptoms. Current evidence for clinical benefits of cannabis is mixed and often inconclusive, largely due to small sample sizes and/or cross-sectional data. To better understand the benefits and risks of cannabis and cannabinoid use during cancer treatment, rigorous longitudinal studies of patient cohorts that document details of cannabis use (i.e. product type, frequency, cannabinoid ratios and potency, and patterns of use) are needed. We aim to achieve this goal by collaborating with the National Cancer Institute Community Oncology Research Program (NCORP), a national network of community oncology clinics. We will recruit a sample of 2000 newly diagnosed cancer patients with breast cancer, non-small cell lung cancer, colorectal cancer, melanoma, or non-Hodgkin lymphoma, to assess the benefits and risks of cannabis and cannabinoid use during treatment. Participants will complete monthly online surveys for 12 months to assess cancer-related symptoms and severity, as well as detailed cannabis and cannabinoid use. This will allow us to (1) describe the longitudinal patterns of use among adult cancer patients during treatment and the effect of individual, clinical and community-level factors on these patterns, and (2) determine the potential benefits and harms of use on cancer and treatment-related symptoms (e.g., nausea/ vomiting, anxiety, neuropathy). We will also assess potential pharmacokinetic and pharmacodynamic effects of use with cancer treatment and changes in inflammatory and toxicity markers by collecting and analyzing biospecimens in a subgroup of lung cancer patients. These data will provide a better understanding of the temporal relationship between heterogeneous patterns of cannabis and cannabinoid use and cancer symptom management; information that will contribute significantly to the design of future clinical trials in cancer care.

NIH Research Projects · FY 2025 · 2023-09

Project Summary Current NIAAA strategic plan calls for efforts to identify novel molecular actions of alcohol and new remedies to mitigate alcohol-impacted brain regions. Ever-changing research tools have exponentially accelerated our understanding of brain regions and circuits affected by alcohol use and comorbid affective disorders. However, efforts towards the understanding of molecular mechanisms for altered neural activity in these impacted regions have lagged behind. To fill in this gap, we will explore a previously unknown molecular mechanism whereby ethanol modulation of brain cholesterol in the prefrontal cortex (PFC) leads to aberrant mGluR2 function and glutamate transmission in a rodent model of chronic intermittent ethanol (CIE) exposure. This modulation may thus contribute to alcohol drinking and anxiety-like behavior, commonly observed in patients with alcohol use disorder (AUD). Using a CIE rodent model, we show that CIE increases glutamate release in the PFC along with increased alcohol drinking and anxiety-like behavior. Further, we and others report that ablation of PFC neuron projection to subcortical regions (e.g. BLA or NAc) abolishes these behaviors. Thus, the PFC is a critical hub for regulating dependence-related neural and behavioral activity. However, the molecular mechanisms underlying CIE-induced disruption of glutamate transmission in the PFC remain elusive. Our preliminary data strongly suggest mGluR2 involvement in this region: a) CIE spatially segregates mGluR2 from Gαo subunit and reduces mGluR2 stimulation of Gαi/o; b) CIE abolishes mGluR2 inhibition of Gβγ-mediated presynaptic glutamate release and postsynaptic intrinsic excitability of PFC neurons; and c) CIE impairs mGluR2 inhibition of anxiety-like behavior. Such a deficit in mGluR2 function may be governed by membrane cholesterol. We found that CIE drastically increases cholesterol content in the PFC by enhancing the activity of HMG-CoA-reductase (HMGCR), a cholesterol synthesis enzyme. Importantly, reduced, CIE- dependent mGluR2 function can be reversed by ex vivo cholesterol removal and mimicked by ex vivo cholesterol addition to naïve tissue. We hypothesize that blockade of cholesterol increase will attenuate CIE- dependent disruption of mGluR2-mediated G-protein activation, neurophysiology and dependence-related behaviors. We will use CRISPR/Cas9, cellular, electrophysiological and behavioral approaches to test our hypothesis. The proposal is conceptually and technically innovative and significant, investigating a largely overlooked and potentially impactful effect of CIE exposure on cholesterol modulation of mGluR2 function, glutamate transmission and anxiety-like behavior.

NIH Research Projects · FY 2024 · 2023-09

PROJECT SUMMARY In 2022, more than 2 million middle and high school students reported current e-cigarette use. The availability of flavored e-liquids makes e-cigarettes particularly appealing to youth, with nearly 85% reporting use of flavored e-cigarettes. The Food and Drug Administration (FDA) has taken action to regulate flavored e- cigarettes. In 2020, the agency banned prefilled, single-use cartridges containing e-liquids in ‘non-tobacco’ flavors (e.g., fruit, candy). It later targeted flavored disposable e-cigarettes—a previously unregulated device type that quickly gained popularity among youth following the initial flavor ban. Until last April, the FDA did not have regulatory authority over synthetic nicotine (vs. tobacco-derived nicotine), which some companies used as a loophole to keep selling flavored e-cigarettes. The ‘partial’ nature of the FDA’s prior regulations enabled e- cigarette manufacturers and retailers the opportunity to circumvent flavor regulations. However, six states (MD, RI, NJ, NY, MA, UT) enacted additional flavored e-cigarette bans, which serve as natural experiments to investigate whether more restrictive flavor bans are more effective in curtailing youth e-cigarette use. Conversely, e-cigarettes may also function as potentially less harmful alternatives for adults who smoke (AWS). Recent clinical trials report greater cigarette cessation rates among participants assigned to e- cigarettes compared to nicotine replacement or counseling only, suggesting potential benefits for those interested in quitting. Since flavored e-liquids are also highly preferred by AWS, e-cigarette flavor bans aimed at reducing AYA e-cigarette use may unintentionally discourage AWS from switching to potentially less harmful products. Thus, the project will examine the public health effects of stricter flavored e-cigarette regulations, taking into account both the potential benefits and risks. Using the Population Assessment of Tobacco and Health (PATH) Survey, we will investigate mechanisms by which statewide flavored e-cigarette bans affect e- cigarette and other tobacco product use (risks) as well as smoking cessation and reduction (benefits). We will leverage the longitudinal attribute of PATH to assess individual behavioral changes between subsequent waves. Using a quasi-experimental event study difference-in-differences estimation design, we will examine (1) changes in e-cigarette and cigarette use across age groups (12-17; 18-24 and 25+) and (2) use of e-cigarettes as a tool to quit or reduce smoking among AWS. PATH also includes a rich dataset of tobacco-related biomarkers, which we will analyze to further explore the impact of flavor bans. This study will contribute highly- relevant data on the positive and negative impact of flavored e-cigarette bans. The proposal aligns with the priorities outlined in RFA-OD-21-003 by examining the use pattern of flavored tobacco products and changes in tobacco use following bans on flavored e-cigarette sales. The study team is comprised of tobacco regulatory science and health policy researchers with the complementary expertise and skillsets needed to accomplish the goals of the proposal.

NIH Research Projects · FY 2025 · 2023-09

AAtrium Health Wake Forest Baptist (AHWFB) has been a NeuroNEXT clinical site (“WAKENN”) since 2018. During our initial funding, WAKENN has been a consistently strong contributor to the NeuroNEXT Network (NN). We have rapidly launched the 3 NN studies available during this 5-year period. We have been a high enroller (N=19) – even being asked to stop enrollment in NN110 to “let other sites have the opportunity to enroll”. Diversity of enrolled participants demonstrates our ability to recruit underrepresented populations; 58% were either female, non-white or Hispanic ethnicity (e.g. 36% were women, 21% were non-white, and 5% were Hispanic). Our other performance metrics are also above average compared to other network sites. WAKENN has a vibrant fellowship. A unique success for WAKENN was the launch of the Wake Investigator Network Development (WIND) to support NN fellows in enhanced training and networking for multi- disciplinary collaboration to advance clinical research and clinical trials. Three fellows (to date) have completed the fellowship program; two have secured independent research funding. During this funding period, the WAKENN clinical footprint has grown considerably because of our partnership with Atrium Health (now 40-hospital health system). This offers new opportunities for collaboration, dissemination, and outreach to underrepresented patients and access to multidisciplinary investigators. We now have two children's hospitals, Brenner’s and Levine Children's Hospital (LCH). LCH is the largest children's hospital between Atlanta and Washington DC, with a catchment of more than 3.5 million. We have clinical experience with gene therapy, active participation in gene therapy trials, and preclinical expertise in gene therapy drug discovery. Our success is because of our dedicated leadership (Ezzeddine, Strowd, Duncan, Munger Clary) and committed team (Sissine, Burgos) and is backed with strong commitments from our department, institution, and the entire Atrium Health system which sees WAKENN as an enterprise-wide priority. This is backed with a solid institutional commitment to meet resource needs as they arise. Our established and active organizational structure, our expertise, and institutional commitment will ensure another successful funding period. We will meet the following aims: AIM 1: To continue to leverage our geographically, ethnically, and economically diverse catchment to effectively enroll and retain clinical trial participants from historically underserved populations. AIM 2: To employ and integrate clinical trial outreach infrastructure across our expanded health enterprise to promote rare and ultra-rare disease NN trials. AIM 3: To leverage the clinical research resources of our integrated academic health enterprise to incentivize, coordinate, and transparently track clinical trial creation, growth, and implementation. AIM 4: To continue to recruit and train the next generation of neuroscience researchers to design and implement meaningful and reproducible trials.

NIH Research Projects · FY 2024 · 2023-09

PROJECT SUMMARY Messenger RNA, or mRNA, and its translation into protein lies at the heart of the central dogma of molecular biology. Converting this basic cellular mechanism into a therapeutic opportunity was the basis of the first two successful COVID-19 vaccines. This technology has the potential to be further advanced into much broader therapeutic modalities, such as a gene replacement medicine for genetic diseases. Currently, mRNA molecules for human therapeutics are generated from biological enzymatic reactions. While this process can create large amounts of material, it suffers from several drawbacks. These include multiple steps in manufacturing, purity, and patient safety. However, the greatest shortcoming is the rapid turnover of mRNA in the body, which severely limits its duration of effect and tunability for a genetic medicine. Unless addressed, this shortcoming will handicap mRNA therapeutics from ever becoming more than a vaccine technology. Chemical modification was the missing ingredient and final piece necessary for the realization of other recently FDA-approved nucleic acid drugs, including antisense oligonucleotides and small interfering RNAs. Chemical modifications enabled nuclease protection, significantly extended drug half-lives, and predictable pharmacological tuning. Likewise, realizing the full potential of mRNA as a human therapeutic will ultimately come down to chemistry. RNA can be chemically synthesized in small fragments. However, no technology exists to easily create long chemically defined translation-competent mRNA molecules. In addition, most of the chemical modifications extensively characterized for their beneficial properties for other nucleic acid therapeutics have not been explored in mRNA research, and certainly not in a therapeutic context. This project proposes to tackle these challenges by generating full-length mRNAs from chemically synthesized fragments, investigating the impact of diverse chemical modifications on mRNA translation, and applying new synthetic chemical methods to make longer mRNAs suitable for human therapeutics. The aims of this proposal are to 1) evaluate the impact of specific nucleotide modifications on model mRNA translation in cells and in vitro, 2) assess the compatibility of triazole linkages with mRNA translation and on-resin “click” chemistry for solid-phase chemical synthesis of longer mRNA, and 3) demonstrate long mRNA chemical synthesis and its potential for therapeutic development in cells and in vivo. The results of this focused project should pioneer a paradigm-shifting approach to mRNA therapeutic development and open new possibilities for conferring better control over the drug properties of mRNA.

NIH Research Projects · FY 2026 · 2023-09

PROJECT SUMMARY / ABSTRACT Approximately 60% of older adults with Alzheimer’s disease or a related dementia (ADRD) have three or more chronic conditions. Multiple chronic conditions (MCCs) and frailty are also risk factors for ADRD and can affect the expression of AD pathology with regards to cognitive function, disease stage, and neuropathological burden. Utilizing biomarkers to diagnosis ADRD may provide a more accurate and cost-effective assessment of the underlying etiology contributing to the cognitive impairment and may guide treatments and counseling about individualized care pathways. However, widespread incorporation of these biomarkers into routine clinical care and population screening programs for older adults with multiple MCCs and cognitive impairment has not occurred. Blood-based biomarkers are now clinically available to aid in the diagnosis of ADRD and are more feasible, especially for older adults with MCCs, and less costly and invasive than CSF or PET-based biomarkers. However, no research has examined these blood biomarkers for the diagnosis and prognosis of ADRD in primary care, especially among diverse populations. It is unknown how and when these blood biomarkers should be used, particularly for diagnosis and prognosis among older adults with MCCs and/or limited life expectancy. Moreover, the effect of MCCs on levels of the biomarkers are not well understood. Numerous other questions remain, such as: 1) whether the ADRD biomarkers enhance prognosis among older adults with MCCs and cognitive impairment; 2) for whom it is most beneficial to obtain ADRD biomarkers including blood, CSF or imaging; 3) how the biomarkers can be implemented in a primary clinical healthcare delivery model; 4) whether there are subgroup differences (e.g. race/ethnicity, sex, MCCs) that affect the interpretation of the biomarkers; 5) assessment of cost estimates and risk/benefit ratios for reimbursement; 6) how best to communicate the results to patients and their caregivers; and 7) the ethical aspects of biomarker collection and potential for incidental findings due to mixed pathologies, especially among older adults. The overall goal of this application is to establish a national consortium, the Alzheimer’s Diagnosis in older Adults with Chronic Conditions (ADACC) Network, consisting of multi-disciplinary investigators that will address these and other questions, and develop evidence-backed strategies and guidelines for the use and implementation of biomarkers for ADRD diagnosis in older patients with MCCs and cognitive impairment. The consortium will have an Executive Committee, Steering Committee, and Data Coordinating Center. It will fund three pilot projects each year and convene an annual meeting. Working groups will be developed to focus on the questions listed above and others. Successful completion of the grant aims will advance the diagnosis and care of older adults with MCCs and cognitive impairment by increasing understanding of how and when to implement ADRD biomarkers.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY Osteoporotic fractures are associated with significant morbidity and mortality, and their U.S. economic burden is projected to reach $20 billion by 2025. Aging accelerates the decline of both muscle and bone, increasing fracture risk. Understanding how muscle and bone interact anatomically, mechanically, and biochemically to reduce bone strength could profoundly advance fracture prevention by identifying new fracture risk screening and intervention targets to diagnose and treat age-related musculoskeletal decline. Computed tomography (CT) scans hold great promise for assessing regional muscle and bone phenotypes to identify older adults at high risk of fracture. Specifically, bone strength – a CT and finite element modeling assessment of 3D bone morphology, bone mineral density (BMD), and cortical thickness – is a stronger predictor of fracture risk than BMD alone. Building on the Study of Muscle, Mobility & Aging (SOMMA), the proposed SOMMA-CT ancillary study is uniquely positioned to explore how thigh and trunk muscle properties from CT (via automated and radiomic analysis), D3Cr muscle mass (D3-creatine dilution), muscle performance, as well as circulating muscle- bone crosstalk biomarkers, relate to changes in bone strength at the hip and spine (2 clinically-relevant fracture sites). SOMMA is a prospective study examining aging-related muscle biology contributions to mobility disability (R01 AG059416). This ancillary study in 360 SOMMA older men and women (ages 70-94) will employ an efficient and cost-effective longitudinal design that adds: 1) a 4th-year follow-up CT scan and blood draw, and 2) advanced processing of baseline and 4-year CT scans and blood samples to extract new longitudinal muscle and bone phenotypes. Specific Aims are to: 1) Determine if muscle quantity and composition (CT- derived thigh and trunk muscle area, muscle density, intermuscular fat, and radiomic texture features of muscle heterogeneity; D3Cr muscle mass) are associated with changes in hip and spine bone strength over 4 years of aging. 2) Determine if muscle performance (leg extensor specific power; 4-m gait speed; time to complete 5 chair stands) is associated with change in hip and spine bone strength over 4 years of aging. We will also explore how biomarkers of muscle-bone crosstalk (myokines: aminobutyric acids; osteokines: CTX-1, P1NP) relate to bone strength both cross-sectionally and longitudinally, and test if these biomarkers mediate the muscle-bone associations in Aims 1-2. The scientific premise is that thigh and trunk muscle degeneration will be associated with declining hip and spine bone strength, and that circulating biomarkers will offer mechanistic insights on muscle-bone crosstalk contributors to bone strength. This investigation in an aging cohort will increase our knowledge of the dynamic interrelationships and crosstalk between muscle and bone. New discoveries in this area could impact over 158 million older adults worldwide who are at high risk of osteoporotic fracture. This work has strong potential to shift clinical practice paradigms by improving predictive power in fracture risk screening and identifying new phenotypes in muscle and/or bone which could be targeted to prevent fracture.

NIH Research Projects · FY 2025 · 2023-09

Project Summary Pathological substance use disorders are devastating psychiatric conditions that lead to patterns of increasing and out of control substance use. These disorders account for significant morbidity and mortality amongst patients and inflict untold costs on their families and loved ones as well as society at large. Of these disorders, pathological use of cocaine and other psychostimulants accounts for a significant proportion of morbidity and mortality. Despite tremendous advances in understanding of the neurobiology of stimulant use disorders, there are no FDA-approved pharmacotherapies for stimulant use disorders. In treating patients with stimulant use disorder, the largest hurdle to overcome is in preventing drug relapse. In recent years there has been a growing understanding that a number of systems outside of the brain can play a critical role in shaping brain and behavior. Among these is the resident population of bacteria in the intestinal tract – collectively referred to as the gut microbiome. Extensive research now demonstrates that changes in the gut microbiome play a critical role in both normal brain function, as well as in the development of pathological states. In our own lab we have previously published that acute depletion of the microbiome can alter the rewarding effects of cocaine and affect gene expression changes in the brain. More recently, we have begun investigating how depleting the microbiome with antibiotics affects the persistence of behavioral and brain gene expression changes in animal models of relapse. We find that animals that lack a complex microbiome have increased cocaine seeking behaviors after a prolonged period of abstinence. Genome-wide RNA-sequencing analyses demonstrate that these animals have robust changes in gene expression in important striatal gene networks that affect synaptic plasticity and behavior. Additional analyses demonstrate epigenetic changes in chromatin structure. Importantly, behavioral and molecular effects of microbiome depletion can be largely reversed by replenishment of specific bacterially derived small molecules. In this grant we will work in two comprehensive Aims to clarify the specificity and mechanisms of these effects and will work to further targeting the gut microbiome and its molecular byproducts. Aim 1 will define temporal specificity of microbiome depletion effects on drug seeking behaviors with targeted microbiome depletions and reconstitutions at different phases of behavior. Behavioral studies will be coupled with molecular analyses of synaptic plasticity related transcriptional and epigenetic effects. Additional analyses of microbiome composition will define bacterial populations associated with increased drug seeking. Aim 2 will further clarify the role of individual microbiome- derived small molecules in driving these behavioral and molecular changes. These studies will provide critical mechanistic insight into gut-brain signaling in a model of cocaine use disorder and will lay the foundation for tractable translational research going forward.

NIH Research Projects · FY 2024 · 2023-09

Project Summary/Abstract Rural Americans experiencing an ST-Elevation Myocardial Infarction (STEMI) are eight times less likely to receive timely definitive treatment than their urban counterparts. This disparity exists even after percutaneous coronary intervention (PCI) times are adjusted for distance to the hospital and exposes rural patients to excess morbidity and mortality. A major obstacle to timely rural STEMI care is a lack of tools available to assist paramedics in providing a consistent evidence-based approach to prehospital STEMI. Our proposal will translate evidenced-based rural Emergency Medical Services (EMS) STEMI best practices into a multifaceted, digital, clinical decision support tool to address this obstacle. This study builds on our team’s foundational mixed methods research that identified (i) previously poorly quantified complexities of rural EMS STEMI care, (ii) barriers to timely care, and (iii) opportunities for improvement. The Rural STEMI Application will be developed, implemented, and refined using an open-source, cross-platform mobile application developed internally by our team. Initially, we will develop and test the usability of the Rural STEMI App in a rural North Carolina County EMS agency to improve prehospital providers’ ability to reduce first medical contact (FMC) to reperfusion (PCI or thrombolytic) times. This will be the first smart device application to provide real-time, evidence-based, guideline-driven, patient-specific treatment assistance for EMS patients with STEMI. We anticipate that the final App will incorporate specific real-time data, including EMS arrival on scene, ECG time, map integrations of nearby emergency departments and catheterization labs, and catheterization lab availability. This novel digital tool will assist the EMS team by providing a scene time countdown, hospital activation metric countdowns, and EMS-specific route navigation assistance to further decrease FMC to reperfusion time. Thus, our application will incorporate critical parameters needed to predict FMC to reperfusion time and identify patients that are better treated with initial thrombolytic administration instead of PCI. Through phased implementation of the Rural STEMI App in seven additional rural EMS agencies, we will evaluate its feasibility and preliminary effectiveness to reduce FMC to reperfusion time. This application will also address the need for improved STEMI encounter communication by providing an automatically generated STEMI feedback report to all key stakeholders. Finally, this proposed study will be the first to apply a mixed methods approach to characterize implementation facilitators and barriers among rural EMS agencies in the care they provide to STEMI patients. By engaging field providers in semi-structured interviews, the study will emphasize quality improvement efforts, EMS administration support, and interdisciplinary collaboration in the care of EMS patients with STEMI. This proposal directly addresses a critical gap regarding how to improve rural prehospital FMC to reperfusion times, which in turn will reduce disparities in morbidity and mortality. We will subsequently test the Rural STEMI App in a large multisystem hybrid effectiveness-implementation trial.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY The proposed study will investigate the role of persistent activity of the lateral prefrontal cortex in object working memory using a non-human primate model. Persistent activity of the prefrontal cortex has long been speculated as the neural correlate of working memory. In recent years alternative models have been proposed, particularly for object working memory. We hypothesize that persistent activity plays a causal role in reflecting the features of remembered stimuli, rather merely representing parameters of the task that subjects perform or highlighting the spatial location of remembered objects. Rhesus macaques will thus be trained in a feature working memory task that will require them to remember and make judgments about visual stimuli. We will record neural activity with a chronic array of microelectrodes, distributed across the surface of the lateral prefrontal cortex, both before and after training. We will test whether the peak of population activity can explain what stimulus the monkeys ultimately remember, and whether drift of this peak of activity over time predicts errors. We will additionally determine how neuronal responses are affected by training by using familiar and novel stimuli in the context of the same working memory task. Moreover, we will directly test the causality of this persistent activity by applying microsimulation on carefully selected electrodes, to cause the animals to erroneously recall not the actual stimulus presented, but the preferred stimulus of the site being stimulated. As a result, the proposed experiments will determine the specific, causal mechanisms in the prefrontal cortex that are ultimately responsible for mediating visual working memory.

NIH Research Projects · FY 2025 · 2023-09

Project Summary/Abstract More than 6 million adults are suffering from heart failure in the United States. Heart failure is associated with high mortality rate while also reducing the quality of life. Early recognition of heart failure and timely interventions can help reducing the disease burden to individuals and to overall healthcare system. However, more than half of HF patients are HF with preserved left ventricular ejection fraction (HFpEF) while the majority of existing HF treatments are for HF with reduced left ventricular ejection fraction (HFrEF). This is because HFpEF is a heterogenous syndrome, and its etiology is not well understood. A new NIH-funded initiative, HeartShare Study, aims to fill this knowledge gap to identify subtypes of HFpEF potentially with different treatment options using deep phenotyping, multi-omics, and machine learning approach. However, there is still a need for low cost and accessible tools 1) for screening large patient populations for HFpEF risk to support preventive risk modification strategies and 2) for identifying HFpEF subtypes to assist targeted therapeutics. The goal of this ancillary study is to utilize low cost and accessible electrocardiogram (ECG) data via artificial intelligence (AI) for prediction of incident HFpEF risk and subtyping of prevalent HFpEF. We and others have shown that AI applied to ECG data can discriminate patients with reduced and preserved EF with high accuracy [1-5]. We recently developed and validated an ECG-based 10-year HF risk prediction model using artificial intelligence (AI) [6, 7]. These findings led us to hypothesize that AI applied to ECG data can predict HFpEF risk and identify specific HFpEF subtypes. The goal of this ancillary study is to test our hypothesis by leveraging retrospective ECG and clinical data from: a) NIH-funded studies with gold standard ascertainment of HFpEFand b) real-world ECG and clinical data from three large healthcare systems (WFU- Wake Forest University, Winston-Salem, NC; UT-University of Tennessee Health Science Center, Memphis, TN; and LUC-Loyola University Chicago) and c) data from the HeartShare Study. Building on our expertise, we propose developing ECG-based risk prediction and classification of HFpEF subtypes by completing three Aims: Aim 1. Develop an incident HFpEF prediction model using data from NIH-funded studies: We will utilize high quality and accurate data from NIH-funded studies to develop AI model predicting risk for incident HFpEF. Aim 2. Develop an incident HFpEF prediction model using real-world Electronic Health Records (EHR)- derived data: We will first utilize very larger and diverse EHR-based real world data to develop incident HFpEF risk prediction model. We will then harmonize it with the NIH-data based model via transfer learning. Aim 3. Develop, test and implement ECG-based HFpEF phenotyping. This aim will utilize data from prevalent HFpEF patients to classify HFpEF subtypes.

NIH Research Projects · FY 2025 · 2023-09

Project Summary Advanced maternal age (≥35 years; AMA) is a steadily increasing public health concern as a non-modifiable risk factor for adverse pregnancy outcomes such as pre-eclampsia, stillbirth, and fetal growth restriction. These outcomes indicate an unfavorable intrauterine environment, which can also predispose offspring to long-term health risks such as cardiovascular disease. The effects of maternal age on the intrauterine environment and developmental programming have only been investigated in a handful of studies, which have shown a slight positive correlation between offspring blood pressure and maternal age in humans, with evidence of diastolic dysfunction and poor response to ischemia in adult male rodents. Non-human primates (NHP), such as the vervet, represent a critical preclinical model of pregnancy that closely mirrors human reproductive anatomy/physiology and fetal development, while allowing for better control over confounders, such as diet and environment. Using the NIH-supported Vervet Research Colony (VRC) at Wake Forest University School of Medicine, as well as the complementary expertise of our multidisciplinary team, we are uniquely poised to longitudinally assess the effects of maternal age on NHP pregnancy physiology and chronic cardiovascular disease in offspring, through a combination of imaging and repeated sampling of blood and placental tissue. We will: 1) Test the hypothesis that NHP AMA pregnancies demonstrate poor maternal cardiovascular adaptation to pregnancy in the form of cardiac diastolic dysfunction using serial echocardiography, blood pressure measurement, and maternal blood biomarker analysis throughout pregnancy in vervets at AMA (11- 14y) and young maternal age (YMA, 5-8y). 2) Test the hypothesis that NHP AMA placentas have evidence of decreased microvascular perfusion using serial contrast-enhanced ultrasound imaging throughout pregnancy, in addition to standard Doppler measurements of uterine/umbilical flow, assessment of fetal growth and survival, and histologic evaluation of placental biopsies throughout pregnancy. 3) Test the hypothesis that adult offspring from NHP AMA pregnancies show evidence of diastolic dysfunction and increased myocardial fibrosis compared to YMA offspring using current 7- to 9-year-old adult vervets and cardiac magnetic resonance imaging techniques to quantify the extracellular volume fraction, a non-invasive measure of myocardial fibrosis. Additionally, we will use echocardiography to quantify diastolic function, measure circulating biomarkers of cardiac strain and remodeling, and interrogate a possible mechanism for developmental programming by measuring components of the renin-angiotensin-aldosterone system. These studies will be among the first to investigate how AMA affects placental function and developmental programming of cardiovascular disease in a clinically relevant NHP model. Understanding the pathophysiological changes that occur in both mothers and offspring from AMA pregnancies is necessary to identify therapeutic targets and critical windows for intervention that can prevent or delay the onset of cardiovascular disease.

NIH Research Projects · FY 2025 · 2023-09

A low nicotine product standard for cigarettes and other combusted tobacco products has been proposed as a cornerstone of the FDA’s Comprehensive Plan for Tobacco and Nicotine Regulation in the United States (US). This proposed standard is based largely on randomized clinical trials demonstrating that when people switch to very low nicotine content (VLNC) cigarettes, cigarettes per day, dependence and biomarkers of smoke exposure decrease and quit attempts and cessation increase. Yet, these trials have important limitations. Notably, they limit the duration of exposure to VLNC cigarettes; cannot recreate the complex context of real-world product standards; are characterized by the use of non-study, normal nicotine cigarettes; and generally focus on samples of convenience. The Smokefree 2025 Action Plan outlines a strategy to reduce smoking prevalence to less than 5%. A major component of the initiative is to mandate a low nicotine product standard for all smoked tobacco. Our primary research objective is to assess impact of a mandated reduction of nicotine in all smoked tobacco products. We propose to conduct a longitudinal, mixed methods cohort study of adults who smoke daily or nearly daily (N=1500), using online surveys, biomarkers of exposure, physiological assessments, qualitative interviews, and medical records to assess changes in smoking behavior, health and well-being. We will follow the cohort for 3.5 years (1.5 years before and 1 year after implementation of a low nicotine product standard). We will also explore potential differences by explicitly sampling individuals with self-reported anxiety and depression, adults with low educational attainment, and heavy alcohol and/or cannabis use. We will also enroll people who smoke but do not have these characteristics. The primary outcome for Aim 1 is abstinence from smoked tobacco (self-reported and biochemically-verified) at 52 weeks after policy implementation. The primary outcome for Aim 2 is Health-Related Quality of Life ratings at 52 weeks after policy implementation. Aim 3 will explore potential differences in response to a low nicotine products standard. As a team, we have complementary areas of expertise (e.g., behavioral pharmacology, public health and medicine, biostatistics, epidemiology, qualitative and mixed methods) to ensure the successful completion of the current proposal.

NIH Research Projects · FY 2025 · 2023-09

PROJECT SUMMARY/ABSTRACT Despite enormous growth in research related to child health and development, there is a significant lag in corresponding growth of this workforce, especially for underrepresented individuals. There remains a dearth of trainees entering into and remaining in these careers. Many pediatricians have limited exposure to research during their training. Those who have received formal research training—ranging from short-term “boot camps” to master’s programs—or who work in a laboratory often are taught how to perform certain research skills (e.g., clinical study design) but do not know how to develop a rigorous research question. Overly specialized research training and lack of funding and resources limit the ability to adapt to a changing environment that is increasingly collaborative. Correspondingly, child health research funding has lagged and is disproportionate to funding for adult-focused research; only 10% of the NIH budget supports child health research (despite that 22% of the US population are children). Thus, there is a need to train individuals in a broad array of pediatric-specific research skills across diverse domains of child health and development in order to optimize their match quality (i.e., aligning their career choice with who they are and their skills and interests) to promote their long-term success. The Wake Forest University School of Medicine (WFUSM) Training in Research Affecting Child Health (TRAC) Program will provide a novel child health and development research training opportunity across the spectrum of educational levels (undergraduate, graduate, and medical students, residents, and fellows). TRAC will foster acquisition of lasting child health-related research skills with an emphasis on independence and critical thinking. Modeled after a WFUSM Department of Pediatrics pilot program, and leveraging existing WFUSM training programs, TRAC will support novel, horizontal peer-to-peer mentorship through an immersive eight-week pediatric-specific skills course over the summer combined with the development and implementation of collaborative research projects with guidance from faculty mentors that will continue throughout the following academic year so participants can see their project to completion. This will culminate in abstract submissions to the Pediatric Academic Societies Annual Meeting the following spring and submission of a first-authored manuscript. This approach will provide an important sense of ownership and accomplishment to further empower the participants and generate excitement to enter the field of child health and development. TRAC will therefore take advantage of a broad educational focus, unique mentorship, and novel participant empowerment to optimize match quality in order to help participants identify and develop their strengths and interests to promote lasting interest in research related to child health and development and enhance the diversity of the research workforce involved in NICHD mission-focused research.